Corrective Action Plans

Finding 564317 (2024-001)

Significant Deficiency 2024

FL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.210 § 200.303

2024-001 – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) (Significant Deficiency) Criteria: According to 2 CFR 200.210(b), a recipient of Federal awards is required to prepare a SEFA for the period covered by the entity’s financial statement which must include the total Federa...

2024-001 – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) (Significant Deficiency) Criteria: According to 2 CFR 200.210(b), a recipient of Federal awards is required to prepare a SEFA for the period covered by the entity’s financial statement which must include the total Federal awards expended. In addition, 2 CFR 200.303 requires non-Federal entities to, among other things, establish, document, and maintain effective internal control over Federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal awards in compliance with Federal statutes, regulations, and the terms and conditions of the Federal awards. Effective internal controls should include procedures to ensure expenditures are properly reported on the SEFA. In addition to providing an accurate SEFA, an organization must also be able to demonstrate that it has a system of internal control that supports the preparation of the SEFA. Condition: The University did not have an adequate process in place to prepare and review its SEFA. Cause: The University’s internal control process for preparing the SEFA did not include review and approval of the SEFA prior to providing it to the auditor. Effect: Failure to accurately report federal expenditures on the SEFA could result in noncompliance with federal regulations. Recommendation: We recommend the University establish, document, and maintain effective internal controls over the preparation of the SEFA. At a minimum, an organization should be able to show documentation that the SEFA was reviewed and approved by an individual who was not directly involved with the initial preparation of the SEFA. The review process should include checking both the reported expenditures of federal awards and the assistance listing numbers reported for each grant program. Action Taken: Management has put in place the following procedures: We will establish, document and maintain effective internal control over Federal awards by performing reconciliation of federal funds at the end of each trimester. The account reconciled will be listed on the SEFA. The Director of Financial Aid will be responsible for preparing the SEFA. It will be reviewed and re-reconciled by the Business Systems Analyst and the FA Asst. Director. Reports used to reconcile come from our Sonis system and are the Award Summary Detail and the Charges and Credits reports. Responsible Party and contact information: Valerie Souza, FA Business Systems Analyst and Lynda Swanson, Asst. Director of Financial Aid. Expected Date of Correction: At the end of each trimester. Full completion of processes will be at the end of our fiscal year/calendar year when audit preparation begins.

View Audit 358473

Finding 564297 (2024-003)

Material Weakness 2024

Brazos Valley Community Action Programs

TX

Reporting Equipment & Real Property Management Matching / Level of Effort / Earmarking

CORRECTIVE ACTION PLANNED: We agree with the finding and have implemented corrective action, including strengthening of written procedures as well as the engagement of outside consultants to assist with training and policy direction. The control deficiencies noted were originally identified in fisca...

CORRECTIVE ACTION PLANNED: We agree with the finding and have implemented corrective action, including strengthening of written procedures as well as the engagement of outside consultants to assist with training and policy direction. The control deficiencies noted were originally identified in fiscal year 2022 but certain programmatic changes delayed full completion of corrective action. However, management believes that now-implemented procedures will address the deficiency in future years. PERSON RESPONSIBLE FOR CORRECTION ACTION: James McCullough, Board President ANTICIPATED COMPLETION DATE: September 30, 2025

View Audit 358437

Finding 564272 (2024-005)

None 2024

Los Angeles Community College District

CA

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

Corrective Actions: The District will continue to focus on learning and improving the delivery of its grant programs. While proud of the effort and engagement demonstrated in this program, which has been recognized as a gold standard for similar programs nationwide, the District is committed to sett...

Corrective Actions: The District will continue to focus on learning and improving the delivery of its grant programs. While proud of the effort and engagement demonstrated in this program, which has been recognized as a gold standard for similar programs nationwide, the District is committed to setting higher goals and expectations. We will continue to work diligently to achieve these ambitious objectives in future programs. Going forward, we will establish a communication protocol with the granting agencies to clarify the program goals and grant requirements as needed. We will implement more frequent monitoring tools for the early identification of potential concerns that may require further attention from the granting agencies. Personnel Responsible for Implementation: Nyame-Tease Prempeh, Director of Accounting, Los Angeles Community College District College Personnel, Grant Coordinators Expected Date of Implementation: December 1, 2024

View Audit 358384

Finding 564262 (2024-002)

Significant Deficiency 2024

Los Angeles Community College District

CA

Questioned Costs Student Financial Aid Special Tests & Provisions

Corrective Actions: A. Incorrect Calculation of Return of Title IV Funds Los Angeles Harbor College The District’s Central Financial Aid Unit (CFAU) R2T4 Unit centralized the R2T4 process at all nine colleges during the 2023-24 aid year. CFAU is currently processing R2T4 calculations for Los Angeles...

Corrective Actions: A. Incorrect Calculation of Return of Title IV Funds Los Angeles Harbor College The District’s Central Financial Aid Unit (CFAU) R2T4 Unit centralized the R2T4 process at all nine colleges during the 2023-24 aid year. CFAU is currently processing R2T4 calculations for Los Angeles Harbor College. Personnel Responsible for Implementation: Ludwig Perez, Financial Aid Manager, Los Angeles Harbor College Steve Giorgi, Financial Aid Manager, Central Financial Aid Unit Expected Date of Implementation: Already Implemented B. Distance Education (DE) Courses – Implementation of Formal Process to Determine Accuracy of Student Withdrawal Date – Partial Implementation of Prior Year Corrective Action Plan (CAP) EPIE will share the most recent annual internal audit review with each college team and require each college to develop a corrective action plan. EPIE will submit a request to add a pop-up message to the faculty roster directly tied to completion of the mandatory exclusion roster (census roster), supplemental roster, and active enrollment roster. The pop-up message will continue to be displayed until the faculty member successfully submits their roster. EPIE will work with the distance education (DE) faculty coordinators to create professional development training geared toward using Canvas to determine an online student’s last date of academic engagement and will offer the training annually. Additionally, EPIE will conduct training for administrators on the use of queries to monitor pending rosters. Personnel Responsible for Implementation: Nicole Albo-Lopez, Vice Chancellor, EPIE Expected Date of Implementation: June 30, 2025

View Audit 358384 Questioned Costs: $1

Finding 564260 (2024-001)

None 2024

Los Angeles Community College District

CA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Corrective Action: The District’s Educational Programs & Institutional Effectiveness (EPIE) and Information Technology (IT) divisions will analyze the current programming and test cases and develop programming to correct the misalignment of the student status effective date reported to the NSC and s...

Corrective Action: The District’s Educational Programs & Institutional Effectiveness (EPIE) and Information Technology (IT) divisions will analyze the current programming and test cases and develop programming to correct the misalignment of the student status effective date reported to the NSC and student status date in PeopleSoft. EPIE will continue to monitor post-submission errors and warning reports to review the effectiveness of the programming change. Personnel Responsible for Implementation: Maury Pearl, Associate Vice Chancellor Andrew Alvarez, IT Business Analyst Stan Levin, Senior Research Analyst Expected Date of Implementation: March 31, 2025

View Audit 358384

Finding 564248 (2024-001)

Material Weakness 2024

Lorna Doone Associates, LLC

UT

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

a. Management is negotiating a solution with the State of Utah and HUD for a refund of the payment.

View Audit 358354 Questioned Costs: $1

Finding 564243 (2024-015)

Material Weakness 2024

Charter County of Wayne, Michigan

MI

Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.303

Condition: The County’s controls over meal participants did not ensure a review was in place to check the intake forms for Halal Home Delivered meal participants or that updated assessments were obtained for home delivered meals. Lastly there was not a control in place to ensure liquid meal particip...

Condition: The County’s controls over meal participants did not ensure a review was in place to check the intake forms for Halal Home Delivered meal participants or that updated assessments were obtained for home delivered meals. Lastly there was not a control in place to ensure liquid meal participants maintained a physician order, renewed every six months, stating the need for the continued supplement service. Planned Corrective Action: Wayne County’s Department of Senior Services will implement processes to ensure only eligible individuals receive meals. A quarterly report will be run to verify all home delivered meal clients have updated assessments and reassessments and will be reviewed by the Department Director and or Division Director quarterly. Halal home delivered meal clients assessments will be reviewed by a second staff member to ensure eligibility and verified by the Department Director and or Division Director monthly. Contact person responsible for corrective action: Joan Siavrakas, Division Director Anticipated Completion Date: 04/25/2025

View Audit 358351

Finding 564239 (2024-002)

Significant Deficiency 2024

Housing Connector

WA

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.306

Corrective action planned: Housing Connector will develop and implement a written policy to address company match contributions used to meet federal cost share requirements, in alignment with 2 CFR 200.306. The policy will provide general guidance on the allowability, tracking, and reporting of matc...

Corrective action planned: Housing Connector will develop and implement a written policy to address company match contributions used to meet federal cost share requirements, in alignment with 2 CFR 200.306. The policy will provide general guidance on the allowability, tracking, and reporting of match to ensure compliance with federal grant regulations. Relevant staff will be informed once the policy is finalized.

View Audit 358335

Finding 564238 (2024-001)

Significant Deficiency 2024

Housing Connector

WA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.430

Corrective action planned: In alignment with 2 CFR 200.430, Housing Connector will develop and implement a formal time tracking policy and procedure to ensure that personnel expenses charged to federal grants are supported by records reflecting the actual time worked on each award.

View Audit 358335 Questioned Costs: $1

Finding 564234 (2024-002)

Significant Deficiency 2024

National Railroad Passenger Corporation

DC

Subrecipient Monitoring Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.302 § 200.303

Finding 2024-002: Review of Compliance Matrices and Narratives The single audit report included the following recommendation: We recommend that Amtrak establishes a more defined timeline for the events that would trigger the update and review of the compliance matrices and compliance narrative, w...

Finding 2024-002: Review of Compliance Matrices and Narratives The single audit report included the following recommendation: We recommend that Amtrak establishes a more defined timeline for the events that would trigger the update and review of the compliance matrices and compliance narrative, which could include execution of any new federal awards or amendments to existing federal awards. Additionally, Amtrak should establish a process where the modifications to the provisions are assessed for materiality/applicability and include documentation of the respective conclusions as part of the review process. Management Response/Status of Action Plans: Amtrak acknowledges the need to augment process documentation around the controls over the preparation and updates to the compliance matrices. The company is in the process of updating these controls now and will incorporate the identified findings in developing more robust controls. The company specifically notes the need to add more documentation on considerations for what provisions are updated in the compliance matrices and the evidence of review. The review procedures and controls are being enhanced to include a checklist to improve the review. This checklist will be completed by both the compliance matrix creator (upon creation) and the compliance matrix reviewer/approver (upon review and final approval). The contact for this item is Lucia Butts, AVP Funding and Grants and Meghan Histand, Director of Discretionary Grants. Amtrak anticipates fully remediating this finding by September 2025.

View Audit 358334

Finding 564143 (2024-001)

Material Weakness 2024

Shelby City School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring HUD Housing Programs

The district will ensure that any contracts that will be paid with Federal Funds will follow the provisions outlined in the grant documentation.

View Audit 358306

Finding 564114 (2024-003)

Material Weakness 2024

Young Men's Christian Association of the Greater Houston Area

TX

Matching / Level of Effort / Earmarking

Finding #2024-003 – Material Weakness and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/23 – 09/30/24, 2402VARVMG-00....

Finding #2024-003 – Material Weakness and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/23 – 09/30/24, 2402VARVMG-00. Condition and context: During our testing of 40 transactions reported as matching grant costs, we identified two exceptions totaling $369 with lack of documentation of fair value of in-kind donations. Additionally, the YMCA did not meet its match requirement by approximately $281,000. Recommendation: Provide additional training and emphasize adherence to established policies and procedures to ensure maintenance of documentation for valuation, documentation and monitoring of matching grant funds. Management’s response: Management agrees with the finding. Continued rapid growth in these programs necessitated significantly greater match requirements, and our internal control procedures around match required expansion. Unfortunately, our organization was not able to keep up with the rate at which these requirements grew. We understand the importance of meeting match obligations and have strengthened procedures in this area to detect and prevent future findings. As we move forward with these programs on a smaller scale, we will ensure that those grants accepted have match levels and requirements that are manageable for our organization. Responsible officer: Jennifer Garcia, Chief Financial Officer. Estimated completion date: June 2025.

View Audit 358211

Finding 564106 (2024-001)

Significant Deficiency 2024

Mental Health America of Dutchess County, Inc.

NY

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

The person responsible for the correcting the finding and timeline are as follows: The Director of Veterans Programs, Alyssa Carion, Due Date: May 1, 2025. Regarding finding #2024-001, all items identified have been addressed and the due date has been met. All missing program agreements noted in the...

The person responsible for the correcting the finding and timeline are as follows: The Director of Veterans Programs, Alyssa Carion, Due Date: May 1, 2025. Regarding finding #2024-001, all items identified have been addressed and the due date has been met. All missing program agreements noted in the SSG Fox audit have been loaded to participant files. Policy and procedures have been updated to state that the patient health questionnaire must be completed by a staff member and a policy for releasing program participants has been added. Tracking participants outside of the online portal is in place and includes enrollment date, disenrollment date for all clients form program inception. In addition, a monthly control is in place to review the spreadsheet o ensure all documents are included.

View Audit 358209

Finding 564101 (2024-003)

Material Weakness 2024

Oak Hill Union Local School District

OH

Matching / Level of Effort / Earmarking Equipment & Real Property Management

Prior to adjusting the expenses related to the evaporator and condenser replacement project to the ESSER Fund, the District conducted due diligence to ensure compliance with Davis-Bacon prevailing wage requirements, as mandated by federal law. Although the initial project quote did not include the r...

Prior to adjusting the expenses related to the evaporator and condenser replacement project to the ESSER Fund, the District conducted due diligence to ensure compliance with Davis-Bacon prevailing wage requirements, as mandated by federal law. Although the initial project quote did not include the required prevailing wage language, the District verified that the wages paid were in accordance with the applicable prevailing wage standards. Furthermore, ESSER guidelines permitted allowable expenditures retroactive to 2020, and the adjustment was made in accordance with those provisions. Moving forward, the District will strengthen its internal controls and procurement procedures to ensure all federally funded contracts include the required prevailing wage clauses.

View Audit 358200

Finding 563976 (2024-003)

Significant Deficiency 2024

County of Kern

CA

Allowable Costs / Cost Principles Period of Performance Significant Deficiency § 200.303

Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were i...

Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were incurred). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor’s Controllers office provides training on accrual basis of accounting at year-end training. All personnel related to recording the expenditures related to this program will be required to attend the meeting. In addition, the Auditor’s office will require all department heads and chief fiscal officers to sign off on the accuracy and completeness of their revenue and expenditures prior to closing each fiscal year going forward. Names of the contact persons responsible for corrective action: Aimee Espinoza, Auditor-Controller and Alonzo Solis, AC Senior Accountant. Planned completion date for corrective action plan: June 30, 2025, is not feasible due to the issuance date so expected completion date to June 30, 2026.

View Audit 358146

Finding 563974 (2024-002)

Significant Deficiency 2024

County of Kern

CA

Allowable Costs / Cost Principles Period of Performance Significant Deficiency § 200.303

Block Grants for Community Mental Health Services - Assistance Listing No. 93.958 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were incurred). ...

Block Grants for Community Mental Health Services - Assistance Listing No. 93.958 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were incurred). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor’s Controllers office provides training on accrual basis of accounting at year-end training. All personnel related to recording the expenditures related to this program will be required to attend the meeting. In addition, the Auditor’s office will require all department heads and chief fiscal officers to sign off on the accuracy and completeness of their revenue and expenditures prior to closing each fiscal year going forward. Names of the contact persons responsible for corrective action: Aimee Espinoza, Auditor-Controller and Alonzo Solis, AC Senior Accountant. Planned completion date for corrective action plan: June 30, 2025, is not feasible due to the issuance date so expected completion date to June 30, 2026.

View Audit 358146

Finding 563847 (2024-001)

Material Weakness 2024

Seminole County Board of Edcuation

GA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: ...

FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021), S425U210012 (Year: 2021) Questioned Costs: $72,595 Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund programs revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were properly recorded. Corrective Action Plans: Our office was unaware our financial program could automatically generate employee's supplemental checks in addition to standard monthly checks. Now that we are aware, Ivey McLendon and I will monitor our financial program's automatically generated claims closely to adapt our manual accrual entries. Estimated Completion Date: June 30, 2025 Contact Person: Sherry Gray, Financial Director Telephone: (229) 524-2433 Email: sgray@seminole.k12.ga.us

View Audit 358065 Questioned Costs: $1

Finding 563806 (2024-002)

Significant Deficiency 2024

Taylor Regional Hospital, Inc.

GA

Significant Deficiency Matching / Level of Effort / Earmarking

Taylor Regional Hospital (Hospital) respectfully submits the following corrective action plan for the year ended March 31, 2024. The findings from the March 31, 2024 Schedule of Findings and Questioned Costs is discussed below. The findings are numbered consistently with the numbers assigned in the ...

Taylor Regional Hospital (Hospital) respectfully submits the following corrective action plan for the year ended March 31, 2024. The findings from the March 31, 2024 Schedule of Findings and Questioned Costs is discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDINGS Significant Deficiency (2024-002) Planned Corrective Action: The hospital agrees with this finding. See 2024-001.

View Audit 358016

Finding 563666 (2024-002)

None 2024

California Institute of Technology

CA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding 2024-002: Common Origination and Disbursement (COD) Reporting Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Pell Grant Program, Federal Direct Loans Award Number: Various Award Year: 10/1/2023-9/30/2024 Assistance Listing Tit...

Finding 2024-002: Common Origination and Disbursement (COD) Reporting Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Pell Grant Program, Federal Direct Loans Award Number: Various Award Year: 10/1/2023-9/30/2024 Assistance Listing Title: Federal Pell Grant Program, Federal Direct Student Loans Assistance Listing Number: 84.063, 84.268 Pass-Through Entities: Not applicable As described in finding 2024-002, 1 of the 25 selections was not reported to the COD system within 15 calendar days of the disbursement to the student. The noted disbursement was reported 5 calendar days late. Caltech confirmed it had additional instances of late reporting beyond the audit selection. To address this finding, Caltech created a Disbursement Checklist to ensure that all steps in the process are followed, including generating common record files of disbursement information and transmitting those files to COD the same day as the funds are disbursed to the student accounts. The checklist was created in May 2025. Malina Chang, Director, Financial Aid Office, is responsible for this corrective action plan. Caltech also performs Pell monthly reconciliations to capture discrepancies between internal information and that which is reported by COD. Any discrepancies are investigated via this monthly reconciliation process, and errors are corrected. In addition, Caltech requests Pell funds from the Department of Education on a quarterly basis (quarterly EDCAPS draws), significantly reducing the risk of the Institute needing to return funds.

View Audit 357971

Finding 563661 (2024-001)

None 2024

California Institute of Technology

CA

Student Financial Aid Matching / Level of Effort / Earmarking

Finding 2024-001: E-Sign Act Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Supplemental Educational Opportunity Grant, Federal Work Study Program, Federal Pell Grant Program, Federal Perkins Loan, Federal Direct Loans Award Number: ...

Finding 2024-001: E-Sign Act Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Supplemental Educational Opportunity Grant, Federal Work Study Program, Federal Pell Grant Program, Federal Perkins Loan, Federal Direct Loans Award Number: Various Award Year: 10/1/2023-9/30/2024 Assistance Listing Title: Federal Supplemental Educational Opportunity Grants, Federal Work-Study Program, Federal Pell Grant Program, Federal Perkins Loan Program, Federal Direct Student Loans Assistance Listing Number: 84.007, 84.033, 84.063, 84.038, 84.268 Pass-Through Entities: Not applicable As described in finding 2024-001, in examining 25 student records, a statement prompting voluntarily consent to participate in electronic transactions was not included in the list of terms and conditions. To address this finding, in March 2025, Caltech revised the Financial Aid Terms and Conditions, found under the student portal, which students must agree to before accepting their financial aid, to include language about voluntarily consenting to participate in electronic transactions. Malina Chang, Director, Financial Aid Office, is responsible for this corrective action plan.

View Audit 357971

Finding 563609 (2024-003)

Material Weakness 2024

Briar Cliff University

IA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Management’s Response: The University has undertaken several initiatives to enhance compliance and accuracy: (1) Collaboration with External Financial Aid Experts a. In 2025, the University engaged an external financial aid contractor to optimize system usage within its database, ensuring more accu...

Management’s Response: The University has undertaken several initiatives to enhance compliance and accuracy: (1) Collaboration with External Financial Aid Experts a. In 2025, the University engaged an external financial aid contractor to optimize system usage within its database, ensuring more accurate and timely reporting. (2) Appointment of a New Financial Aid Director a. A new Financial Aid Director has been hired, commencing their role on March 1, 2025. This leadership is expected to prioritize and address the issues identified in the audit finding. (3) Process Enhancement and Staff Training a. A comprehensive assessment of current enrollment reporting procedures has been conducted to identify and rectify gaps. b. Staff members in the Registrar’s Office have undergone targeted training to ensure accurate and timely updates to the National Student Loan Data System (NSLDS). (4) Policy and Procedure Development a. New policies and procedures have been established to verify that correct effective dates and status changes are reported to NSLDS within the required timeframes. b. Regular audits and reviews are now in place to ensure ongoing compliance and to promptly address any discrepancies. These initiatives demonstrate the University’s commitment to maintaining accurate student enrollment records and ensuring compliance with federal regulations, thereby safeguarding the interests of its students and the institution.

View Audit 357880

Finding 563602 (2024-003)

Significant Deficiency 2024

Olmsted County Housing and Redevelopment Authority

MN

HUD Housing Programs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Audit Finding Number: 2024-003 Cash Management Agency: Department of Housing and Urban Development Responsible Person, Title: Karla Strain, Assistant Controller Completion date: 5/15/2025 Agency Response: Concur Corrective Action Plan: In response to these findings, the Authority has reviewed and ...

Audit Finding Number: 2024-003 Cash Management Agency: Department of Housing and Urban Development Responsible Person, Title: Karla Strain, Assistant Controller Completion date: 5/15/2025 Agency Response: Concur Corrective Action Plan: In response to these findings, the Authority has reviewed and revised its Capital Fund cash management procedures to ensure full compliance with the Capital Fund Handbook. The updated procedures have been reviewed in collaboration with both the Housing Project Manager and the Housing Program Manager. Invoices will be organized to fulfil the monthly obligation and paid within three days of the fund draw. To prevent recurrence and ensure ongoing compliance, the Authority will hold monthly meetings to review project timelines and cash flow needs. Communication frequency will increase during complex, multi-phase projects to support effective oversight and coordination. Furthermore, updated policy and payment procedures will be clearly communicated to all current and future vendors to ensure alignment with federal regulations. These corrective actions reflect the Authority’s commitment to improved financial oversight and adherence to all applicable funding regulations.

View Audit 357879

Finding 563033 (2024-027)

Material Weakness 2024

City of Baltimore, Maryland

MD

Reporting Material Weakness Period of Performance § 200.302 § 200.303

Finding 2024-027 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-023 Auditee’s Corrective Action Plan: BCHD fiscal department contin...

Finding 2024-027 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-023 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562904 (2024-023)

Material Weakness 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring Eligibility Material Weakness § 200.302 § 200.303

Finding 2024-023 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-019 Auditee’s Corrective Action Plan: BCHD fiscal department continues to rev...

Finding 2024-023 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-019 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562864 (2024-021)

Material Weakness 2024

City of Baltimore, Maryland

MD

Reporting Subrecipient Monitoring Material Weakness § 200.302 § 200.303

Finding 2024-021 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-016 Auditee’s Corrective Action Plan: The Federal Financial Report (FFR) is a cumu...

Finding 2024-021 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-016 Auditee’s Corrective Action Plan: The Federal Financial Report (FFR) is a cumulative report covering the entire project or award period, which for this grant spans from March 1, 2020, to February 28, 2025. As a result, the cumulative amounts reported on the FFR will not align with the amounts recorded in the general ledger for fiscal year 2024. BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established the Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Corrective Action Plans

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